Impact of adherence to key performance indicators on mortality among patients managed for ischemic stroke

Main Article Content


Stroke, Brain Ischemia, Risk Factors, Anticoagulants, Guideline Adherence, Professional Practice, Mortality, Registries, Prospective Studies, Survival Analysis, Malaysia


Background: Stroke is a leading cause of death worldwide. The cases of acute ischemic stroke are on the increase in the Asia Pacific, particularly in Malaysia. Various health organizations have recommended guidelines for managing ischemic stroke, but adherence to key performance indicators (KPI) from the guidelines and impact on patient outcomes, particularly mortality, are rarely explored.  

Objective: This study aims to evaluate the impact of adherence to key performance indicators on mortality among patients managed for ischemic stroke.

Methods: We included all first-ever ischemic stroke patients enrolled in the multiethnic Malaysian National Neurology Registry (NNeuR) - a prospective cohort study and followed-up for six months. Patients’ baseline clinical characteristics, risk factors, neurological findings, treatments, KPI and mortality outcome were evaluated. The KPI nonadherence (NAR) and relationship with mortality were evaluated. NAR>25% threshold was considered suboptimal.

Results: A total of 579 first-ever ischemic stroke patients were included in the final analysis. The overall mortality was recorded as 23 (4.0%) in six months, with a median (interquartile) age of 65 (20) years. Majority of the patients (dead or alive) had partial anterior circulation infarct, PACI (43.5%; 34.0%) and total anterior circulation infarct, TACI (26.1%; 8.8%). In addition, DVT prophylaxis (82.8%), anticoagulant for atrial fibrillation (AF) patients (48.8%) and rehabilitation (26.2%) were considered suboptimal. NAR < 2 was significantly associated with a decrease in mortality (odds ratio 0.16; 0.02-0.12) compared to NAR>2. Survival analysis showed that death is more likely in patients with NAR>2 (p=0.05).

Conclusions: KPI nonadherence was associated with mortality among ischemic stroke patients. The adherence to the KPI was sub-optimal, particularly in DVT prophylaxis, anticoagulant for AF patients and rehabilitation. These findings reflect the importance of continuous quality measurement and implementation of evidence recommendations in healthcare delivery to achieve optimal outcome among stroke patients.

Abstract 1059 | pdf Downloads 456


1. Johnston SC, Mendis S, Mathers CD. Global variation in stroke burden and mortality: estimates from monitoring, surveillance, and modelling. Lancet Neurol. 2009;8(4):345-354.
2. Rajsic S, Gothe H, Borba HH, Sroczynski G, Vujicic J, Toell T, Siebert U.Economic burden of stroke: a systematic review on post-stroke care. Eur J Health Econ. 2019;20(1):107-134.
3. GBD 2016 Stroke Collaborators. Global, regional, and national burden of stroke, 1990–2016: A systematic analysis for the Global Burden of Disease Study 2016. Lancet Neurol. 2019;18(5):439-458.
4. GBD 2015 Neurological Disorders Collaborator Group. Global, regional, and national burden of neurological disorders during 1990–2015: A systematic analysis for the Global Burden of Disease Study 2015. Lancet Neurol. 2017;16(11):877-897.
5. Benjamin EJ, et al. Heart Disease and Stroke Statistics—2019 Update: A Report From the American Heart Association. Circulation. 2019 Mar 5;139(10):e56-e528.
6. Katan M, Luft A. Global Burden of Stroke. Semin Neurol. 2018;38(2):208-211.
7. Mehndiratta MM, Khan M, Mehndiratta P, Wasay M. Stroke in Asia: Geographical variations and temporal trends. J Neurol Neurosurg Psychiatry. 2014 Dec;85(12):1308-1312.
8. Aziz ZA, Lee YY, Ngah BA, Sidek NN, Looi I, Hanip MR, Basri HB. Acute stroke registry Malaysia, 2010-2014: Results from the National Neurology Registry. J Stroke Cerebrovasc Dis. 2015;24(12):2701-2709.
9. Loo KW, Gan SH. Burden of stroke in Malaysia. Int J Stroke. 2012;7(2):165-167.
10. Tharakan J. Stroke registry-relevance and contributions. Med J Malaysia. 2012;67(3):251-252.
11. Hwong WY, Aziz ZA, Sidek NN, Bots ML, Selvarajah S, Kappelle LJ, Sivasampu S, Vaartjes I. Prescription of secondary preventive drugs after ischemic stroke: Results from the Malaysian National Stroke Registry. BMC Neurol. 2017;17(1):203.
12. Hasan TF, Rabinstein AA, Middlebrooks EH, Haranhalli N, Silliman SL, Meschia JF, Tawk RG. Diagnosis and management of acute ischemic stroke. Mayo Clin Proc. 2018;93(4):523-538.
13. Goyal M, Fargen KM, Menon BK. Acute stroke, Bayes’ theorem and the art and science of emergency decision-making. J Neurointerv Surg. 2014;6(4):256-259.
14. Romano JG, Smith EE, Liang L, Gardener H, Camp S, Shuey L, Cook A4, Campo-Bustillo I, Khatri P, Bhatt DL, Fonarow GC, Sacco RL, Schwamm LH. Outcomes in mild acute ischemic stroke treated with intravenous thrombolysis: a retrospective analysis of the Get With the Guidelines–Stroke registry. JAMA Neurol. 2015;72(4):423-431.
15. Fonarow GC, Smith EE, Saver JL, Reeves MJ, Bhatt DL, Grau-Sepulveda MV, Olson DM, Hernandez AF, Peterson ED, Schwamm LH. Timeliness of tissue-type plasminogen activator therapy in acute ischemic stroke: patient characteristics, hospital factors, and outcomes associated with door-to-needle times within 60 minutes. Circulation. 2011;123(7):750-758.
16. Fonarow GC, Zhao X, Smith EE, Saver JL, Reeves MJ, Bhatt DL, Xian Y, Hernandez AF, Peterson ED, Schwamm LH. Door-to-needle times for tissue plasminogen activator administration and clinical outcomes in acute ischemic stroke before and after a quality improvement initiative. JAMA. 2014;311(16):1632-1640.
17. Fonarow GC, Reeves MJ, Smith EE, Saver JL, Zhao X, Olson DW, Hernandez AF, Peterson ED, Schwamm LH; GWTG-Stroke Steering Committee and Investigators. Characteristics, performance measures, and in-hospital outcomes of the first one million stroke and transient ischemic attack admissions in get with the guidelines-stroke. Circ Cardiovasc Qual Outcomes. 2010;3(3):291-302.
18. Heuschmann PU, Berger K. International experience in stroke registries: German Stroke Registers study group. Am J Prev Med. 2006;31(6 Suppl 2):S238-S239.
19. Wang Y, Li Z, Zhao X, Liu L, Wang C, Wang C, Peterson ED, Schwamm LH, Fonarow GC, Smith SC Jr, Bettger J, Wang D, Li H, Xian Y, Wang Y. Evidence-Based Performance Measures and Outcomes in Patients With Acute Ischemic Stroke: Findings From the China National Stroke Registry. Circ Cardiovasc Qual Outcomes. 2018;11(12):e001968.
20. Hsieh F, et al. Taiwan stroke registry investigators. Get with the guidelines-stroke performance indicators: surveillance of stroke care in the Taiwan stroke registry: get with the guidelines-stroke in Taiwan. Circulation. 2010;122(11):1116-1123.
21. LaBresh KA, Reeves MJ, Frankel MR, Albright D, Schwamm LH. Hospital treatment of patients with ischemic stroke or transient ischemic attack using the “Get With The Guidelines” program. Arch Intern Med. 2008;168(4):411-417.
22. Schwamm LH, Fonarow GC, Reeves MJ, Pan W, Frankel MR, Smith EE, Ellrodt G, Cannon CP, Liang L, Peterson E, Labresh KA. Get With the Guidelines-Stroke is associated with sustained improvement in care for patients hospitalized with acute stroke or transient ischemic attack. Circulation. 2009;119(1):107-115.
23. Ellrodt AG, Fonarow GC, Schwamm LH, Albert N, Bhatt DL, Cannon CP, Hernandez AF, Hlatky MA, Luepker RV, Peterson PN, Reeves M, Smith EE. Synthesizing lessons learned from get with the guidelines: the value of disease-based registries in improving quality and outcomes. Circulation. 2013;128(22):2447-2460.
24. Kalkonde YV, Alladi S, Kaul S, Hachinski V. Stroke Prevention Strategies in the Developing World. Stroke. 2018;49(12):3092-3097.
25. Centers for Disease Control and Prevention (CDC). Prevention. Use of a registry to improve acute stroke care--seven states, 2005-2009. MMWR Morb Mortal Wkly Rep. 2011;60(7):206-210.
26. Grube MM, Dohle C, Djouchadar D, Rech P, Bienek K, Dietz-Fricke U, Jöbges M, Kohler M, Missala I, Schönherr B, Werner C, Zeytountchian H, Wissel J, Heuschmann PU. Evidence-based quality indicators for stroke rehabilitation. Stroke. 2012;43(1):142-146.
27. Rohde A, Worrall L, Le Dorze G. Systematic review of the quality of clinical guidelines for aphasia in stroke management. J Eval Clin Pract. 2013;19(6):994-1003.
28. Kernan WN, Ovbiagele B, Black HR, Bravata DM, Chimowitz MI, Ezekowitz MD, Fang MC, Fisher M, Furie KL, Heck DV, Johnston SC, Kasner SE, Kittner SJ, Mitchell PH, Rich MW, Richardson D, Schwamm LH, Wilson JA; American Heart Association Stroke Council, Council on Cardiovascular and Stroke Nursing, Council on Clinical Cardiology, and Council on Peripheral Vascular Disease. Guidelines for the prevention of stroke in patients with stroke and transient ischemic attack: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2014;45(7):2160-2236.
29. Jauch EC, Saver JL, Adams HP Jr, Bruno A, Connors JJ, Demaerschalk BM, Khatri P, McMullan PW Jr, Qureshi AI, Rosenfield K, Scott PA, Summers DR, Wang DZ, Wintermark M, Yonas H; American Heart Association Stroke Council; Council on Cardiovascular Nursing; Council on Peripheral Vascular Disease; Council on Clinical Cardiology. Guidelines for the early management of patients with acute ischemic stroke: A guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2013;44(3):870-947.
30. Nazifah SN, Azmi IK, Hamidon B, Looi I, Zariah A, Hanip M. National Stroke Registry (NSR): Terengganu and Seberang Jaya experience. Med J Malaysia. 2012;67(3):302-304.
31. Amarenco P, Bogousslavsky J, Caplan L, Donnan G, Hennerici M. Classification of stroke subtypes. Cerebrovasc Dis. 2009;27(5):493-501.
32. Appleton JP, Woodhouse LJ, Adami A, Becker JL, Berge E, Cala LA, Casado AM, Caso V, Christensen HK, Dineen RA, Gommans J, Koumellis P, Szatmari S, Sprigg N, Bath PM, Wardlaw JM; ENOS Investigators. Imaging markers of small vessel disease and brain frailty, and outcomes in acute stroke. Neurology. 2020;94(5):e439-e452.
33. Micieli G, Cavallini A, Quaglini S; Guideline Application for Decision Making in Ischemic Stroke (GLADIS) Study Group. Guideline compliance improves stroke outcome: a preliminary study in 4 districts in the Italian region of Lombardia. Stroke. 2002;33(5):1341-1347.
34. Rudd AG, Williams LS. Advances in health policy and outcomes. Stroke. 2009 May;40(5):e301-e304.
35. Bravata DM, Wells CK, Lo AC, Nadeau SE, Melillo J, Chodkowski D, Struve F, Williams LS, Peixoto AJ, Gorman M, Goel P, Acompora G, McClain V, Ranjbar N, Tabereaux PB, Boice JL, Jacewicz M, Concato J. Processes of Care Associated With Acute Stroke OutcomesStroke Outcomes and Processes of Care. Arch Intern Med. 2010;170(9):804-810.
36. Sargin M, Tasdemir MM, Kuplay H, Erdogan SB, Tandogar N, Akansel S, Kurc E, Orhan G, Aka SA.Retrospective cohort study for evaluating the INR monitoring patterns in patients with deep vein thrombosis in daily practice: Analysis of 2010–2013 database of a tertiary care center. Phlebology. 2019;34(5):317-323.
37. Wei JW, Wang J-G, Huang Y, Liu M, Wu Y, Wong LK, Cheng Y, Xu E, Yang Q, Arima H, Heeley EL, Anderson CS; ChinaQUEST Investigators. Secondary prevention of ischemic stroke in urban China. Stroke. 2010;41(5):967-974.
38. Gallacher KI, McQueenie R, Nicholl B, Jani BD, Lee D, Mair FS. Risk factors and mortality associated with multimorbidity in people with stroke or transient ischaemic attack: a study of 8,751 UK Biobank participants. J Comorb. 2018;8(1):1-8.
39. Habibi-koolaee M, Shahmoradi L, Niakan Kalhori SR, Ghannadan H, Younesi E. Prevalence of Stroke Risk Factors and Their Distribution Based on Stroke Subtypes in Gorgan: A Retrospective Hospital-Based Study - 2015-2016. Neurol Res Int. 2018;2018:2709654.
40. Shinton R. Lifelong exposures and the potential for stroke prevention: the contribution of cigarette smoking, exercise, and body fat. J Epidemiol Community Health. 1997;51(2):138-143.
41. Evans A, Perez I, Harraf F, Melbourn A, Steadman J, Donaldson N, Kalra L. Can differences in management processes explain different outcomes between stroke unit and stroke-team care? Lancet. 2001;358(9293):1586-1592.
42. Indredavik B, Bakke F, Slørdahl S, Rokseth R, Haheim L. Treatment in a combined acute and rehabilitation stroke unit: which aspects are most important? Stroke. 1999;30(5):917-923.
43. Saposnik G, Fang J, O'Donnell M, Hachinski V, Kapral MK, Hill MD; Investigators of the Registry of the Canadian Stroke Network (RCSN) for the Stroke Outcome Research Canada (SORCan) Working Group.. Escalating levels of access to in-hospital care and stroke mortality. Stroke. 2008;39(9):2522-2530.
44. Urimubenshi G, Langhorne P, Cadilhac DA, Kagwiza JN, Wu O. Association between patient outcomes and key performance indicators of stroke care quality: A systematic review and meta-analysis. Eur Stroke J. 2017;2(4):287-307.

Most read articles by the same author(s)

1 2 3 4 5 6 7 8 9 10 > >>